Highlighted Areas Are "FINRA/Compliance Required Data"
Personal Information
Do you have a spouce? Yes   No
  CLIENT SPOUSE  
LAST NAME Do you have a:
FIRST NAME/MIDDLE NAME

Will?

Power of Attorney?

Trust?

Estate Plan?
ADDRESS
 
 
DATE OF BIRTH
SOCIAL SECURITY NUMBER Phone No
Drivers License Number Home :
State Issued Work :
Issue Date / Exp Date Cellular:
Occupation  
Employer  
Employer Address  
Est. Retirement Age  
E-Mail Address  
Dependents
  NAME Date of Birth Relationship
 
 
 
 
 
 
       
Beneficiary Info (Please check below)
    NAME DOB Social Security Number % Allocated
Primary Contingent
Primary Contingent
Primary Contingent
       
Assets
Income Categories Specifics Estimated Monthly Income Estimated Annual Income
Work Employer $ $
Employer (spouse) $ $
    $
Personal Savings and Investments Savings $ $
Checking $ $
Other (Money Mkt, CD's, etc.) $ $
    $
Roth IRA   $ $
  $ $
    $
IRA, SEP, Other   $ $
  $ $
    $
Oualified ERISA 401k $ $
Oualified ERISA 403b $ $
Pension $ $
Pension $ $
Monthly Total $ $
    $
Social Security Client   $
Spouse   $
    $
Other Income Rental Income, Inheritance, etc. $
       
Expenses
Expense Categories Specifics Current Monthly Amount Total Annual Amount
Home Mortgage / Rent $ $
Interest Rate % Years Remaining  
Property Taxes $ $
Utilities (power, heat, water) $ $
  Sub total $
Current Value    
     
Essentials Food / Groceries $ $
     
Medical Bills $ $
Medicine $ $
Vehicle Loan Payments $ $
Fuel $ $
     
Childcare $ $
  Subtotal $
Insurance Life Insurance $ $
Long Term Care $ $
Medical $ $
Vehicle $ $
Homeowner / Rental $ $
Disability $ $
  Subtotal $
Debt Credit Cards $ $
Loans $ $
  Subtotal $
Taxes


Bracket %
 Federal $ $
State $ $
Local $ $
  Sub Total $
Income Taxes: Income Taxes: If
we do not prepare your tax returns,
please provide a copy of your most
recent return for us to review.		      
Additional financial information and expenses
What are your other investments (includes other assets held by LPL)? Please indicate percentage of net worth (must equal 100%)
Real Estate % Mutual Funds % Insurance % Checking %
Savings % Annuities % Equities % Bonds %
Alternative Investments % Other %        
If other, please explain      
What is your investment time horizon for this account?
One to three years Three to five years Five to 10 years More than 10 years
       
Do you have liquidity needs from the funds in this account?
Yes NO    
If yes, when do you need these funds?   Zero to three years Zero to three years
If yes, specify the approximate dollar amount for the time range indicated above. $
     
Client Signature Date :
Received by: JFR Financial Services, Inc. on
Per FINRA Rules 2111 and 2090: All highlighted areas are mandatory. Other sections are used by us
to develop your plans, but not required to meet FINRA compliance requirements.
     
Investment Risk Tolerance (1 = low; 10 = high) : 1 2 3 4 5 6 7 8 9 10
Do you have any addtional comments about your finances?
I/We reviewed each question/section and provided answers to the best of my/our ability. I understand that any recommendations made
assume the information I provided herein is accurate.
Client Signature :   Date :
 
 

Securities offered through LPL Financial, Member FINRA/SIPC. Investment advice offered through JFR Financial Services, Inc., a registered Investment Advisor and separate entity from LPL Financial.